Establish Practice-specific 1995 Detailed Examination Guidelines

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October 6, 2010
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By Pam Brooks, CPC, PCS

The question, “What constitutes a detailed examination in the 1995 Documentation Guidelines for Evaluation and Management Services?” conjures up ambiguous responses regarding evaluation and management (E/M) documentation criteria. For detail-oriented coders, this gray area is responsible for lengthy discussions, confusion, and occasional misinterpretation—because there is no black-and-white answer.

There are many ways for coding departments to clarify and to standardize “gray area” coding situations. One option is to establish practice-specific 1995 detailed examination guidelines. This will help external auditors assess documentation compliance and provide coding education to physicians. Besides providing a standardized audit tool, it ensures a consistent auditing process, regardless of coder interpretation and skill, which National Health Insurance Company (NHIC) acknowledges as an issue.

Evaluate Detailed Examination Guidance

The Centers for Medicare & Medicaid Services (CMS) and CPT® both describe the 1995 detailed examination as, “an extended examination of the affected body area(s) and other symptomatic or related organ system(s).” Contractors don’t offer much additional explanation. Trailblazer explains the difference between the 1995 expanded problem focused exam and the detailed exam as, “the difference in the detail in which the 2-7 examined systems are described.” Noridian, WPS, Palmetto, and National Government Services (NGS) follow CMS. NHIC is a bit more forthright, and suggests: “The 1995 Guidelines are less precise. For example, they allow the physician (and the auditor) to choose their own definitions of ‘detailed’ examination of an organ system. On audit, this vagueness often leads to differences of opinion—even among expert coders—on the appropriate level of examination on any given chart.”

NHIC is correct: Some coders will count 2-4 organ systems/body areas (OS/BA) to determine an expanded problem focused exam, while counting 5-7 OS/BA to satisfy a detailed exam. Other coders use the 1995 guidelines for all but the detailed exam, and rely on the “12 bullets in 6+ organ systems” criteria from the 1997 Documentation Guidelines for Evaluation and Management Services to support a detailed exam. Other coders rely on the 1997 guidelines entirely, to avoid the ambiguity of the 1995 guidelines. None of these are wrong, and there is no quick and easy answer, but it is a good idea to determine a method specific to your practice/specialty, and use it consistently to keep your auditing process compliant.

Most coders and physicians prefer the 1995 guidelines because they tend to be “easier” for the physician to achieve. By using NHIC’s suggestion to choose specifically your own definition of a “detailed” examination, you can develop practice-specific 1995 examination guidelines to clarify issues. This way, the internal auditing process is standardized, as is your creation of an audit tool specifically for the 1995 detailed exam.

Determine Criteria

Because the 1995 guidelines already indicate that 2-7 organ systems and/or body areas should be examined, this is the starting point for determining the “detailed” criteria.

Ask yourself, “What constitutes a full examination within any one OS/BA?” When determining this, decide whether to list all possible bullets for each OS/BA, and consider a detailed examination as the documentation of 50 percent or more of these bullets. This would enable you to find a happy medium between the documentation of only two organ systems. This seems inadequate to support a detailed exam—and the documentation of 12 bullets in six OS—which frequently is difficult to achieve. To determine all examination options for each OS/BA, CMS’s 1997 Documentation Guidelines for Evaluation and Management Services can be used to note every bullet item within each obtainable OS/BA (www.cms.gov/MLNProducts/Downloads/MASTER1.pdf).

For instruction regarding examination methods and documentation, reference the medical student textbook Bates’ Pocket Guide to Physical Examination and History Taking (Lippincott Williams & Wilkins, Philadelphia, 2007). This book is particularly helpful in explaining unfamiliar examination techniques to the non-clinician. Overall, it’s important to identify those examination components used in both the general medical and specialty comprehensive exams.

For example, the male genitourinary (GU) exam could include:

GU Male

  • exam of scrotum
  • exam of penis
  • digital rectal exam of prostate gland
  • exam of urethra
  • exam of bladder

If you keep with the proposed idea that a detailed examination includes documentation of 50 percent or more of the above bullets, then a detailed male GU examination would show, in a dictated note, performance of any three of the five bullets. To complicate matters, because many physicians now use an electronic medical record (EMR) to document their office and progress notes, this creates an entirely new auditing and documentation challenge.

Look Into EMR Auditing Challenges

Most EMRs allow providers to select many additional examination bullets within the individual OS/BA templates, which are not necessarily the same as those published in the CMS 1997 guidelines. To determine additional options, you can set up a test patient within your EMR to undergo an examination and select every examination bullet. This allows a look at the actual office note language that would print to the medical note for every possible examination scenario. From this language, you can determine two things:

  1. Whether the creation of practice-specific 1995 examination guidelines should include additional examination bullets; and
  2. If the default EMR language would ‘fit’ within the already-established 1997 bullets.

Many sophisticated EMR software packages are able to document examination bullets such as “Babinski reflex” and unfamiliar acronyms that may require additional research and coder/auditor training. The additional research and training is to identify the appropriate bullets and to familiarize coding staff with the rationale of these examination elements for medical necessity. The items listed in blue below indicate common EMR-specific language that most closely fits under the existing 1997 bullets for the male GU exam:

GU Male

  • exam of scrotum

hair distribution, epididymides, testes

  • exam of penis
  • digital rectal exam of prostate gland
  • exam of urethra
  • exam of bladder

Some EMR language may show that another bullet in the integumentary system exam would be appropriate, as in this example:

Integumentary

  • inspection of skin and subcutaneous tissue and nails
  • palpation of skin and subcutaneous tissue and nails
  • inspection of hair distribution and quality

When the number of possible bullets under each OS/BA is determined, you can decide whether 50 percent or more of these bullets would indicate a detailed 1995 examination. Ask providers to weigh in on whether this “50 percent or better” approach is reasonable from a clinical, medically-necessary standpoint.

A pulmonary specialist reviewed the five possible bullets for the respiratory examination below and determined that three of the five bullets were likely to be addressed in a detailed examination within his specialty.

Respiratory 3/5

  • inspection of chest with notation of symmetry and expansion

tenderness

  • assessment of respiratory effort

cough

  • percussion of chest
  • palpation of chest
  • auscultation of lungs

Implement and Evaluate the Audit Tool

When the draft audit tool of the 1995 detailed examination guidelines is complete, take time to get feedback regarding content and layout of the audit tool. Ask other coders to use this tool for their daily pre- and post-billing audits to determine usability and feasibility by implementing it with your standard E/M audit tool (specifically to validate the detailed examination).

Pay attention to up/down coding when using the new exam audit tool. Query the physicians who have been identified systematically as not meeting the guidelines (due to the new tool’s use) to decide if the new guidelines are too rigid, or if these physicians need help with documentation.

Applying other guidelines during the tool’s implementation is optional. You may decide not to count constitutional organ system as one of the systems qualifying for a detailed exam. For example, if the provider documents three or more vital signs, the overall appearance of the patient, and a cardiovascular exam only, the cardiovascular exam is required to meet the detailed criteria to support a detailed exam. Otherwise, an expanded-problem focused exam is warranted, even with the documentation of a detailed constitutional exam. This prevents providers from documenting a detailed examination without addressing any of the organ system(s) affected in the history of present illness (HPI) and review of systems (ROS).

It might make sense to mandate an expanded-problem focused exam to meet medical necessity; the documentation of a detailed examination must be within the organ system(s) related to the nature of the presenting problem. Multi-specialty practices should decide if there needs to be a single detailed 1995 examination guideline, or if a series of specialty-specific guidelines best serves the group. Regardless of which choice is made, the guideline usage should be constant so the physicians are audited on a level playing field.

One Response to “Establish Practice-specific 1995 Detailed Examination Guidelines”

  1. Diane says:

    Great tips for this gray area – will suggest to my clients – Thanks

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